Last week I was trying out my new camper-trailer driving on a dirt road in the mountains heading for secluded camping spot. As the road got narrower and rougher I was beginning to have doubts when I saw an older fellow camping by the road. I stopped to ask him if I could get to my destination on this route. He stopped, looked at me and my rig and said “Yes, but maybe that’s not where you want to go?” We engaged in shared decision making and I safely found a wonderful spot for my trip.
“Yes, but maybe that’s not where you want to go?”
Shared decision making is important when providers, patients and family are talking about interventions that have potential for benefits but also high burdens and risk. Examples are LVAD, PSA Screening and in the case of a recent article Lung Cancer Screening with low dose CT Scans. People who smoke cigarettes are at higher risk for lung cancer and it is thought that diagnosis at an earlier stage when curative treatment was an option could improve survival. There have been 4 large RCTs on screening and 3 found no benefit but one did demonstrate reduced mortality with screening. However, there was a 98% false positive rate. In other words, 1 person out of 50 identified for additional work-up actually had cancer. This false positive news creates anxiety and the potential risk of biopsy and even surgery for what is not cancer.
When CT screening for lung cancer was approved by CMMS they required shared decision making, preferably with a decision aid, before consenting and referring people for testing. It makes sense because this is a rocky and risky path that people are considering starting out on. A recent study, using big data, found very few conversations about screening (millions of Americans are potential candidates) and the quality of those conversations scored a 6 out of 100. Clearly a failing grade.
Apparently, healthcare providers in general, are not up to the job of having shared decision making conversations. Fortunately, my new camping buddy was.
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